Form SI204-F001

REV.03-03-16

Quality Control Non-Conformance Report

SI JOB NO.: REPORT DATE:

PROJECT NAME: REPORT NUMBER:

CLIENT NAME: QC NAME:

PROJECT NAME: LOCATION:
A: Description of Non Conformance Additional files/documents attached Pictures attached
(enter detailed description of the nonconformance, including the spec or code number and paragraph for which this does not meet the
acceptance criteria here. Also include details of whom was informed of this, and what time and date they were informed)

B: Recommended Corrective Actions

(enter detailed description of your recommendations to remedy this non conformance and any additional details from other management
regarding this issue)

C: Disposition and Required Actions

Note: Corrective actions that will not result in conformance to Contractual requirements (i.e. Specs, Codes, Drawings,
Scope etc.) require Client disposition and approval and and RFI must be processed to obtain client approval.
(enter detailed description of the nonconformance, including the spec or code number and paragraph for which this does not meet the
acceptance criteria here. Also include details of whom was informed of this, and what time and date they were informed)

Name Date Signature

Disposition By: (SI Manager) - see note above)

Acknowledged By: (QC Lead)

Acknowledged By: (Construction Supt. or PM)

D: Verification of Completion and Close-Out

The following actions were taken and completed.

The below signed agree that this Non-Conformance is closed and requires no further actions.
Name Date Signature
SI Supt.: (Client or SI Manager) - see note above)

SI QC: (QC Lead)

Client: (Construction Supt. or PM)

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Form SI204-F001
REV.03-03-16

Quality Control Non-Conformance Report

SI JOB NO.: REPORT DATE:

PROJECT NAME: REPORT NUMBER:

CLIENT NAME: QC NAME:

PROJECT NAME: LOCATION:
E: Recommended Preventive Actions
As applicable, list the recommended actions that should be taken to prevent recurrence of this type of non conformance.

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